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'PX'(WjeK <br /> �ice,)ISDD �)oaquin County-Environmental Health Depal <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 20Y-468-3420 1��J�® <br /> �� <br /> �q <br /> SA ENVIRON AR MENI APPLICATION I01 <br /> H�UTH pE <br /> ENVIRONMENTALRMITO OPERATETH EN PIERMM SNTAL HSALTH <br /> EMPLOYEE HOUSING OR LABOR CAMP ERVICES <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) JffAnnual Permit for Calendar Year AJO XX <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit 1D#• 0027815 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: BONNIE PLANTS Location: 23975 E MILTON RD,LINDEN <br /> Operator: DE LA MADRID, MIGUEL <br /> Mailing Address: 23975 E MILTON RD, LINDEN CA 95236 Facility Phone#:(619)664-6921 <br /> Legal Owner: DE LA MADRID, MIGUEL New Owner? ❑Yes R No <br /> Owner Address: 23975 E MILTON RD,LINDEN CA 95236 Owner Phone#:(619)664-6921 <br /> Community Facilities Provided by Camp: Community Kitchen? ® Yes ❑ No <br /> Men: Number of Toilets 3 Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> (lousing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildinizs Employees <br /> Dormitories —� <br /> from to / / y Z Crop <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: IVT <br /> MH/RV Spaces Note EIVED <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit 2021 <br /> El Inactive <br /> 1 m norta n : In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this app FI,JQAQUIN COUNTY <br /> Fee Schedule HEALTH DEPARTMENT <br /> ® Permanent Camp Annual Permit Fee $50.00+ Number of Employees 110 @$15.00 each=$ I a 9 <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees 0 @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application 4 <br /> TOTAL FEE DUE a <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name 6 A I Gk V4-(,( G Title S r.9 rlt),J M, ,j4Ctg(L. ❑Partnership <br /> (Please PRINT or TYPE) BaCorporation <br /> Address RS 'T I 1 7<9 C41 `15�L3(P Phone (S-31) .531— 1800 <br /> Applicant Signature �GC1�ti Date of Application ;k. 1 ;l.0 1 A ( <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 2 �3 w 2 08 � �, !; <br /> 0050073 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0026344 PR0546475 2765 9834-SUSZYCKI N/A <br /> Report#:7066 Application Printed:12/2/2021 <br />